Timothy J. Daskivich, MD
Although High-intensity focused ultrasound (HIFU) is only approved in the United States for prostate tissue ablation, it has demonstrated efficacy as a treatment for patients with prostate cancer, says Timothy J. Daskivich, MD.
Daskivich noted, however, that HIFU must be used in the proper setting to avoid overtreatment. “We need to be careful with who we treat with upfront focal therapy. We shouldn't overuse HIFU for very low-risk tumors, or the majority of low-risk tumors because they should be managed with active surveillance,” said Daskivich.
“Select intermediate-risk tumors are the ones we can capture with HIFU; that’s the best use of the technology. As far as imaging goes, multiparametric MRI is going to become the standard of care for patients on active surveillance. It may even become the standard of care for identifying disease in patients with elevated prostate-specific antigen,” Daskivich added.
In an interview during the 2018 OncLive®
State of the Science Summit™ on Genitourinary Cancers, Daskivich, an assistant professor of surgery at Cedars-Sinai Medical Center, discussed optimizing the use of HIFU and other treatment strategies in the prostate cancer armamentarium.
OncLive: When will we see the widespread adoption of HIFU?
HIFU has been FDA approved since October 2015 for the treatment of prostate tissue. It’s now used by many academic centers across the United States for treatment of patients with prostate cancer. It's been used in Canada, Mexico, and Europe for the last 20 years to treat prostate cancer, so there's a track record elsewhere. We’re going to see more use of focal therapy as experience in the United States evolves.
What are other imaging modalities that are used?
Multiparametric MRI is an excellent modality for identifying high-grade tumors. It has a 20% miss rate. The beauty of it is that it ignores low-grade tumors. Low-grade tumors, such as Gleason 6 tumors, are ones we now watch and don't treat aggressively. Often, we don't want to find them in older men because that can lead to harmful overtreatment. Cedars-Sinai Medical Center has developed a platform for high-resolution MRI that improves resolution over multiparametric MRI by about six-fold. It identifies 60% of tumors that are invisible to multiparametric MRI.
PET-MRI is another modality, but it is only available at a handful of centers across the United States; Cedars-Sinai Medical Center is one of them. Ongoing clinical trials are investigating the use of PET tracers like fluciclovine to identify tumors within the prostate gland.
How can rates of active surveillance be improved to avoid overtreatment?
It has to be driven by patient education and physician uptake. In the academic community, everyone believes active surveillance is the way to go for very low-risk prostate cancer and the majority of low-risk prostate cancers. I always tell patients, “The best treatment is no treatment.” That’s how I start every conversation about prostate cancer.